ERC - post ROSC care Flashcards
You’ve achieved ROSC - talk through ABC and what you’d do
A - insert advanced airway if significant cerebral dysfunction
B - aim for 94-98% sats, normocapnia, CXR, NG tube to decompress stomach
C - ECG, access + adrenaline + dobutamine + fluids if necessary to keep sBP >100
You have a post ROSC HR of 35, is this ok?
As long as…
BP >100
urine output >1ml/kg/hr
sats 94-95%
You’ve got ROSC and have gone through ABC - now for a diagnosis… what investigatios do you do
likely cardiac: coronary angiopgraphy and PCI
not likely cardiac: CT brain or CTPA
What things happen in ICU post ROSC
Temp controlled 32-26 for 24 hours at least normoxia normocapnia normoglycaemia normokalaemia
when is the post ROSC neurological assessment carried out
72 hours - after TTM and rewarming
what are some confounders to the post ROSC neurological assessment
sedation and neuromuscular blocking agents hypoglycaemia hypothermia severe hypotension electrolyte derangements
State some findings of post ROSC neurological assessment that indicate a poor prognosis
CT head - loss of sulci, reduction of the GM/WM ration, diffuse anoxic brain injury
MRI - diffuse ischaemic changes
status myoclonus
Bilateral absent corneal and pupillary reflex
bilaterally absent N20 SSEP wave
high NSE and S-100B markers
EEG: no activity, status epilepticus, unreactive burst suppression
What is SSEP
somatosensory evoked potentials - EEG activity in response to tactile stimulation
What is NSE
neuron specific enolase - a biomarker released from dead neurones
Name 2 biomarkers used in post ROSC prognostication
NSE - released from neurones
S-100B - released from glial cells
what things on an EEG indicate poor post ROSC prognosis
no activity
status epilepticus
unreactive burst-suppression
What is unreactive burst-suppression on an EEC
> 50% of the EEC consists of voltage <10uV with alternating bursts
What does N20 SSEP mean
corresponds to arrival of the nerve impulse at the primary somatosensory region
What benefits does sedation offer post ROSC
stops shivering so TTM easier to maintain
reduces metabolic rate and oxygen demand
benefits of TTM on a cellular level
reduced apoptosis
reduced cerebral metabolism therefore reduced free radical production
reduced inflammation
blocks intracellular consequence of excitotoxin exposure
what temperature and for how long are patients cooled in TTM
32-36 degrees C
>24 hours
who is TTM considered in
unresponsive post ROSC
initial shockable rhythm
adults
what drug can be given to reduce the threshold for shivering
MgSO4
how is the temperature monitored in TTM
thermister in bladder or oesophagus
how many degrees/hour is a patient rewarmed after TTM
0.25 - 0.5 degrees c/hour
which patients should be considered for post ROSC ICD insertion
those with significant LV dysfunction suffering from a ventricular arrhythmia >24 hours after the primary occlusive event
which drugs are effective in treating post anoxic myoclonus
propofol
sodium valproate
levetiracetam
what is self-fulfilling prophecy
a bias occuring when physicians are not blind to the result of the outcome predictor and use it to make decisions on withdrawal of life sustaining treatment
what imaging can aid in prognostication
CT - reduction in GM/WM ratio, loss of sulci
MRI - diffuse ischaemic changes
